Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

PLEASE NOTE: by clicking the submit button (below) you are giving your consent to participate in the screening/monitoring program, if you do not wish to participate you need not do anythnig further . 

____ I have read the provided information about the Ages & Stages Questionnaires (ASQ-3), and I wish to have my child(ren) participate in the monitoring program. I will fill out the questionnaires about my child's development and promptly return the completed questionnaires through the online questionnaire completion system.

____ I do not wish to participate. I have read the provided information about the Ages & Stages Questionnaires (ASQ-3) and understand the purpose of this program.

Parent/Guardian Signature

Please Print Parent/Guardian Name

Date

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.